Are you a communication lobbyist?Are you the spouse or dependent child of a communication lobbyist?Are you a principal of a state contractor or prospective state contractor?If yes, please indicate if contract is with Legislative or Executive branch of government, or both.Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?Please indicate the number of tickets purchased and the ad type.

I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

I certify that as the individual contributor, I have provided my residential address, employer and principal occupation.

I certify that I am NOT a principal of a state contractor or prospective state contractor.

I certify that this contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds; the name on the card is the name provided above, payment on this card is not made from the funds of a corporation, labor organization or any other entity.

I certify that if I am a communicator lobbyist or the immediate family member of a communicator lobbyist that my contributions are limited to no greater than $100.

I certify that this contribution is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

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Connecticut General Statutes § 9‐612 (f) (2) (A) & (B) provide in part that no state contractor, prospective state contractor, principal of a state contractor or principal of a prospective state contractor, with regard to a state contract or state contract solicitation with or from the General Assembly, Executive Branch, or a quasi public agency or a holder, or a principal of a holder of a valid prequalification certificate, shall make a contribution to a party committee.

$100 Lobbyist Contribution Limit

Connecticut General Statutes § 9‐610 (g) provides in part that no communicator lobbyist or member of the immediate family of a communicator lobbyist shall make a contribution or contributions to, or for the benefit of a party committee in excess of one hundred dollars.

“Public Official” Exemption

Please Note: The state contractor contribution bans do not apply to a principal of a state contractor or prospective state contractor who is an elected public official. See General Statutes § 9-612 (f) (4). Likewise, the communicator lobbyist contribution limit does not apply to a spouse or dependent child of a communicator lobbyist who is an elected public official. See General Statutes § 9-610 (j).

Definition of Terms

“Party committee”: a state central committee or a town committee. See General Statutes § 9‐601 (2).

“Individual contributor”: a human being, a sole proprietorship, or a professional service corporation organized under chapter 594a and owned by a single human being. A sole proprietorship is a business in which one human being owns all the assets, owes all the liabilities, and operates in his or her personal capacity. Any other type of business is not permitted to make a contribution, including LLCs. See General Statutes § 9-601 (9).

“State contract”: an agreement or contract with the state or any state agency or any quasi-public agency, let through a procurement process or otherwise, having a value of fifty thousand dollars or more, or a combination or series of such agreements or contracts having a value of one hundred thousand dollars or more in a calendar year, for (i) the rendition of services, (ii) the furnishing of any goods, material, supplies, equipment or any items of any kind,

(iii) the construction, alteration or repair of any public building or public work, (iv) the acquisition, sale or lease of any land or building, (v) a licensing arrangement, or (vi) a grant, loan or loan guarantee. “State contract” does not include any agreement or contract with the state, any state agency or any

quasi-public agency that is exclusively federally funded, an education loan, a loan to an individual for other than commercial purposes or any agreement or contract between the state or any state agency and the United States Department of the Navy or the United States Department of Defense. See General Statutes § 9-612 (f) (1) (C).

“State contractor”: a person, business entity or nonprofit organization that enters into a state contract. Such person, business entity or nonprofit organization shall be deemed to be a state contractor until December thirty‐first of the year in which such contract terminates. “State contractor” does not include a municipality or any other political subdivision of the state, including any entities or associations duly created by the municipality or political subdivision exclusively amongst themselves to further any purpose authorized by statute or charter, or an employee in the executive or legislative branch of state government or a quasi‐public agency, whether in the classified or unclassified service and full or part‐time, and only in such person’s capacity as a state or quasi‐public agency employee. See General Statutes § 9‐612 (f) (1) (D).

“Prospective state contractor”: a person, business entity or nonprofit organization that (i) submits a response to a state contract solicitation by the state, a state agency or a quasi‐public agency, or a proposal in response to a request for proposals by the state, a state agency or a quasi‐public agency, until the contract has been entered into, or (ii) holds a valid prequalification certificate issued by the Commissioner of Administrative Services under section 4a‐100. ʺProspective state contractorʺ does not include a municipality or any other political subdivision of the state, including any entities or associations duly created by the municipality or political subdivision exclusively amongst themselves to further any purpose authorized by statute or charter, or an employee in the executive or legislative branch of state government or a quasi‐public agency, whether in the classified or unclassified service and full or part‐time, and only in such person’s capacity as a state or quasi‐public agency employee. See General Statutes § 9‐612 (f) (1) (E).

“Principal of a state contractor or prospective state contractor”: (i) an individual who is a member of the board of directors of, or has an ownership interest of five per cent or more in a state contractor or prospective state contractor, which is a business entity, except for an individual who is a member of the board of directors of a nonprofit organization, (ii) an individual who is employed by a state contractor or prospective state contractor, which is a business entity, as president, treasurer or executive vice president, (iii) an individual who is the chief executive officer of a state contractor or prospective state contractor, which is not a business entity, or if a state contractor or prospective state contractor has no such officer, then the officer who duly possesses comparable powers and duties, (iv) an officer or an employee of any state contractor or prospective state contractor who has managerial or discretionary responsibilities with respect to a state contract, or (v) the spouse or a dependent child who is eighteen years of age or older of an individual described in (i), (ii), (iii), or (iv). See General Statutes § 9-612 (f) (1) (F).

“Communicator lobbyist”: a lobbyist who communicates directly or solicits others to communicate with an official or his staff in the legislative or executive branch of government or in a quasi-public agency for the purpose of influencing legislative or administrative action. A lobbyist, in turn, is generally defined as a person who, in lobbying and in furtherance of lobbying, makes or agrees to make expenditures, or receives or agrees to receive compensation, reimbursement, or both, and such compensation, reimbursement or expenditures are $3,000 or more in any calendar year or the combined amount thereof is $3,000 or more in any such calendar year. See General Statutes § 1-91 (12) & (22) (as amended by Public Act 15-15).

“Immediate family”: The spouse or a dependent child of an individual. See General Statutes § 9-601 (24).

“Dependent child”: a child residing in an individual’s household who may legally be claimed as a dependent on the federal income tax return of such individual. See General Statutes § 9-612 (f) (1) (G).